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Most older adults with drinking problems are encountered in nonaddictions settings, seeking assistance (or referred for assistance) for something other than an alcohol-related problem. Although they may acknowledge use of alcohol, they may not see it as a problem or have any intention of making long-term drinking-related changes. Thus, they are in either the precontemplation or the contemplation stage of change. Despite neither problem awareness nor intent to change, the contact with a health care or social services professional provides a chance for an opportunistic intervention. Such contacts offer chances to educate older people about how alcohol effects change as people age. Brief, hospital-based early intervention programs have been shown to be effective in encouraging clients, many of whom are in the precontemplation stage of change, to reduce alcohol use and accept referrals for treatment (Welte, Perry, Longabaugh, & Clifford, 1998).
Given that many older adults experience alcohol-related problems, professionals must remain alert to the possibility with all clients they encounter. In addition, they should guard against misinformation and biases about alcohol abuse and aging that hamper efforts to explore the possibility of problem drinking with clients. Interviewers should routinely include questions about drinking practices and alcohol consumption in all initial screening and assessment interviews. Screening questions should be asked in private locations that ensure confidentiality and communicate respect. They should be linked to the concerns for which the client is seeking assistance. Edwards and colleagues (1997) suggested that practitioners should anticipate clients' reactions to questions about alcohol use and use "disarming" statements to normalize the focus on drinking (for example, "I always ask people about their drinking practices, because it is important to be able to talk about all aspects of one's life."). These statements can be followed by a combination of open-ended and focused questions, delivered in a respectful, nonjudgmental, concerned manner, to help the practitioner understand the client's drinking and its fit in his or her life context.
Professionals can blend questions from the CAGE screening instrument (Buchsbaum et al., 1992) into an interview unobtrusively. CAGE consists of four questions (Have you ever thought about cutting down on your drinking? Do you get annoyed when people question or express concern about your drinking? Have you ever felt bad or guilty about your drinking? Have you ever drunk first thing in the morning when you get up, to steady your nerves or to treat a hangover [eye opener]?). Answers are scored 1 for "yes" and 0 for "no." A score of two or more is presumptive of a drinking problem, but an affirmative answer to any question should trigger fuller exploration and assessment.
Several other signs should alert a practitioner to a potential alcohol-related problem and should trigger more in-depth assessment:
Information about drinking and its impact in a person's life paired with a recommendation to cut down can lead to reductions in alcohol consumption (Babor, 1994). However, to build motivation for sustained change, feedback must raise clients' awareness of the nature and extent of alcohol-related difficulties, affirm and validate their experiences, help them identify alternative courses of action, and give clear advice about the importance of doing something about their situations (Fleming, 2002).
Screening interviews should help clients take the "next" steps toward a fuller assessment and treatment, if indicated. Commitment to this process is strengthened by using client-centered interviewing strategies, directly addressing doubts the client might have, and actively involving the client in developing a viable action plan (Miller & Rollnick, 2002). The plan should include specification of the changes a client wants to make (for example, changes in alcohol consumption, becoming more socially active in a community center [a goal for an older adult who drinks heavily when he or she feels isolated and alone]); statements concerning the main personal reasons (motivations) for making the changes (for example, clients say they want to feel happier with their lives or they want to reconcile with their children); particular steps a client plans to take to effect change (for example, removing alcoholic beverages from his or her apartment); the names of people who can help and how they can help (for example, family members, friends, and professionals who can provide encouragement, transportation, or feedback); specification of people and situations that may interfere with change and what can be done about them (for example, staying away from friends with whom the client drinks or relatives who are overly critical of the client); and personalized criteria clients can use to judge the plan's effectiveness.
Spousal influence is an important factor in older adults' drinking (Graham & Braun, 1999). Thus, involving clients' families can increase the success of motivational counseling. Assuming a client is willing to involve a significant other, the role the other takes depends on the degree of interpersonal commitment between the client and the other, as well as the other's willingness to get involved. In cases where a client does not identify the other's role as important and the significant other has little investment in the client's sobriety, Burke and colleagues (2002) suggested that the person assume a "witness" role. That is, he or she provides information about the effects of the client's drinking, but takes no part in developing an action plan to change the behavior. In cases where there is high interpersonal commitment and interest on the other's part, he or she can become more active in promoting commitment to change and helping the client in mutually agreeable ways. Minimal or no involvement of the other should occur when there is a high level of interpersonal stress and hardship. In these latter cases, practitioners may need to help the other person disengage from the client and address his or her own concerns before trying to help the client.
Reflection Exercise #8